February 02, 2014

We didn’t know we were “crowdfunding” when we started The Thicket Society – the term hadn’t shown up yet. It was Joanne Marshall’s idea. Get a few of our friends to chip in a few bucks to help cover the cost of renting the gear. I don’t know whose idea it was to do the t-shirts. We hadn't a clue what it would become.

It’s been an amazing run, but we’ve decided that Boston was the last “official” MLA/Bearded Pigs gig.

In San Diego it was eight friends and two twelve packs and we were tucked into an unused meeting room that Ray arranged for us. It was low-key, just an excuse for us to get together and play. At the San Diego Zoo the next day Tambourine Grrl saw the pen with the bearded pigs in it and we had a band name. In DC the next year we put up a poster and 50 people came. Folks went to the liquor store across the street and brought booze back. The hotel was not amused and threatened MLA with a charge of several thousands of dollars for “trashing the room.” Rock stars!

By the time we got to Phoenix the crowd was rising and the next year, in Philadelphia, I saw more people dancing that I didn’t know than people I did. Folks were stacked up in the hallway trying to get into the room. “What are all these people doing here?” I wondered, as I hammered another E chord. “We’re not that good…” But we had something. I've been looking at the pictures. What times we had!

But each year was a bigger production. TG would start designing the t-shirts in March, but she’d still be scrambling to finish it up in time to get the shirts delivered to the hotel the day before we arrived. Duke and I would spend hours on the logistics of gear rental, and then there’d be the hauling and setup and tear down. Rolling and labeling the shirts over bloody marys on Saturday morning to try to get them to registration by noon. For the sheer joy of those three hours on a Sunday night we all put in hours and hours of planning and work. Thank goodness we never actually practiced – where would we have found time for that?

It was worth it. But it wasn’t what I’d signed up for.

Don’t get me wrong – I loved it and I am forever grateful to the Thicket Society members who made it possible for us to do the gigs and to all of the people who showed up. But every year we’d get done and I’d think, “The work to fun ratio is not quite tilting in my favor anymore.” And I’d wonder if I really wanted to do it again the next year.

It was after Seattle, during the summer of 2012, that it seemed to me we’d come to the end of that road. I wasn’t ready to break it to the band, but I decided that Boston would be the last official MLA gig.

We gathered for dinner at the Summer Shack and I laid it out for them. Time to go out on a high note. There was no disagreement. We’d already done so much more than we ever imagined. It’s been a wonderful gift. I hope we’ve given people at least a small measure of pleasure for all that they’ve given us.

Boston was a great gig – certainly one of the very best. With my short-circuited nervous system I couldn’t play guitar, but I could still belt out the vocals. The change in instrumentation made everybody step up their game. And we had the amazing Jack running the mixers and making us sound better than ever. But as great as it was, I didn’t waver on the decision.

So that’s it for The Thicket Society. No more buttons, no more shirts. Of course it is not the end of the band. Although MLA was always the highlight of the year, we've always managed to find other times and places to play. We never know where and we never know when, but we do know The Bearded Pigs will play again… and again… Who knows, it might even happen at an MLA near you. We’ll keep it a surprise.

January 09, 2014

When I looked at my phone and saw that someone from Neurology had left me a message a few minutes earlier, I thought it was a coincidence. But no, it was Dr. B: “… Your MRI of the cervical spine looks much better, with significant improvement in the swelling and in the scar that you had compared to before. So it seems that the Cytoxan is doing what it’s supposed to with reduced inflammation, so my suggestion would be to continue the treatment…”

I was astonished at how quickly I got the results. It was 5pm when I was being rolled out of the MRI machine. By the time I got home, 40 minutes later, an alert had been sent to my doc to tell him that the results of a test he’d ordered were available, he’d looked at the scans, made his assessment, called and left the message. I was flooded with relief. I’d been fully prepared to have to wait a couple of days for the results.

The news was what we’d been expecting, but you never know. I was steeled against the possibility that despite the symptom improvements of the last couple of months, the MRI scans wouldn’t show much reduction in the inflammation. My poor spinal cord! My crazy relentless immune system! My achy, twitchy muscles! But now we know that there is at least a chance for some of the compressed nerves to resume functioning and for the other nerves to find new pathways to carry messages from my brain to my limbs. Miranda talks about the fabulous “neuroplasticity” of the human body. That’s what I’m counting on.

By coincidence, an article about my situation appeared this week on the UAB Medicine website. Of course, I hate the picture (the only pictures of myself that I like are ones that include Josie), but it does a pretty good job of addressing my situation and, more importantly, the quality of care that I’ve been receiving. (There is one unfortunate error in the story – it refers to my attending a meeting of the “Division of Medical Journals.” It was actually the Editorial Board of the BMJ – British Medical Journal.)

UAB has a well-deserved reputation for clinical excellence, but I don’t think the story of how much emphasis is placed on the overall patient experience is as well told as it ought to be. Yes, what I’m dealing with is tough – imagine how much worse it would be if not for all of the amazing people who’ve had a hand in my care!

So we’ll count on the cytoxan (cyclophosphamide) infusions to keep the inflammation down. I know there won’t be any dramatic improvements. On any given day some things feel a little better and some are a little worse. The struggles are never-ending. But overall, things are moving in the right direction. Maybe not at the speed of light – but we’re moving.

December 19, 2013

When you see a determined young woman treading the clinic or hospital hallways and notice a string of safety pins dangling from the pocket of her white coat, you know she’s a neurologist. I tease the residents that now I know why they went into neurology – so they could play with the high tech tools. The safety pin. The sharp stick. The tuning fork.

Last Wednesday was my first visit to my neurologist in three months, and after a year of this I could do the assessment myself – squeezing the hands while the patient tries to keep his fingers spread, pushing down on the knee, pulling the arms forward. Dr. B. will take the tuning fork to see if I can feel the vibration on the back of my wrist, on my knee, on my shin.

But I was most curious about the safety pin. He’ll have me close my eyes and then alternate touching me with the point and the top of the clasp. Can you feel this? Can you tell which one was sharp? He’ll touch the backs of my hands and then move up my shins.

It has been my impression, these last seven weeks since we started the cyclophosphamide infusions, that my skin sensitivity is improving (not always pleasantly, but I’ll take more sensation over less). But in the dark before dawn, when I drift awake briefly, and my muscles go through their sequence of twitches and spasms, I have doubts. Maybe I’m just imagining the improvements, subtle as they are. Because maybe I need to.

But he smiles. “Definitely improving. Much stronger. Much better sensation.” I have trouble recognizing my own relief.

So we’ll continue with the monthly infusions, at least through March. He’ll taper me off the prednisone (I’m very glad about that – it’s been making me grumpy). I’ll keep on with the physical therapy.

Part of what makes my condition challenging for the caregivers is that it is unlike a spinal cord injury, where there is a single traumatic event. In my case, the spinal cord has been under attack for over a year and we have no way of knowing what the extent of irreversible damage has been. I imagine the battle ground – we are trying to get the healthy nerves to forge new pathways, to develop the connections to the muscles that have been lost by the nerves that will never fire properly again. But these nerves are under attack too, and too often (I imagine) the inflammation gnaws their insulating myelin away before they can retool and they become useless as well. In those dark hours I wonder, even if we are successful in getting the inflammation substantially reduced, will there be enough healthy nerves left? In that little inch or two of firestormed spinal cord I do not have an infinite supply of neurons.

But here Dr. B. sounds a hopeful note that I hadn’t considered. Some of the nerves are being compressed by the swelling that accompanies the inflammation and that compression is rendering them inadequate. But they may not be seriously damaged, and as the swelling decreases, some of them will be restored to functioning properly. There’s a glimmer that I’m happy to have.

We’ll do another MRI in early January so that we can see the status of the inflammation. But for now we can infer that it is going down some. Now it is up to me, with Miranda’s help, to strengthen the muscles and retrain the nerves. While the cyclophosphamide works its vile, but oh so necessary magic, I’ll do my leg lifts and torque my hip muscles and practice my lunges and squats, and pedal away.

I’m prepared for the long journey. For now the improvements remain slight and scarcely observable to the untrained eye. My walking is shaky and weak, my hands can still barely grip and I have no dexterity. How much function I will eventually get back remains as unknown as ever. I know I’m not going to wake up one morning and be miraculously restored.

That’s okay. I’m very happy that we’ve got a plan for the next few months. The improvements are real. The treatment is working. And I know what I need to do.

November 23, 2013

“You got this, Nonai!” I’m bending down ever so slowly to pick up a pencil that’s dropped to the floor and Josie is cheering me on just as she would a teammate about to execute a backwalkover backhandspring on the balance beam. “Good job, Nonai!” she says, as I straighten back up, pencil in hand. She gives me a high five.

The improvements are subtle, but they’re definite. Starting about five days after the first cyclophosphamide infusion I began to feel a bit more control of my trunk muscles. By last week, I could feel the right hip muscles that I haven’t been able to get at for months. They’re very weak, but when Miranda (my PT) tells me to flex them in order to keep from hyperextending my knee joint, I can kinda do it. Most days it seems that I have a little more flexibility in my fingers – I put Marian’s housekey on my keyring and I don’t think I could have done that a month ago.

None of this has translated into major functional improvements. Miranda says she can see the improvement in my gait – if she squints. I can feel the difference, but getting from place to place isn’t any easier.

Still, I’m encouraged. I had the second infusion on Wednesday. We’ll see over the next few days if there are any observable effects from this one.

Marian and Lynn were in Las Vegas for the Gymboree annual meeting, so I stayed at Josie’s house, getting her to and from school and gymnastics, making sure she got her homework done. As we’ve said before, she is my medicine and it was quite clear that we were doing equal parts of taking care of each other.

At the gym I stand by the rail watching her and her teammates fly through the air while I work on lifting one leg and then the other (“I saw you doing your exercises while you were watching me,” she says when she finishes up). I think it ought to make me feel bad to watch them be so impossibly graceful and limber when I can hardly walk – but it doesn’t. I just feel joyful watching them and amused to find myself in this situation.

I can’t explain it, other than with the echo of JoBug’s voice in my head, “You got this, Nonai!”

July 24, 2013

Sitting near the ocean over the long 4th of July weekend I’m reading Granta 120, the Medicine issue, and the first prose piece I come to
is M.J. Hyland’s Hardy Animal, the
tale of her struggles after being diagnosed with multiple sclerosis.

As if I needed the reminder of
how lucky I am. But of course I do -- my own transverse myelitis has many of the same symptoms as MS, but at least some of the possible prognoses are much more positive (never mind that at the moment I'm still in the limbo of uncertainty about the cause and anything could happen. We'll get back to that).

Hyland’s diagnosis shattered her sense of her
self. She'd worked hard to overcome the toughness of her upbringing and that brought with it a certain (unjustified) sense of invulnerability. That her brain and body seemed to have turned against her undermined the carefully constructed self that she relied on. She felt isolated from everybody.

In contrast, here I am, in the strong embrace of these three women, who love me as well as one can be loved, with whom I am spending
a lovely long weekend in exquisite surroundings. Despite all of my own neurotic worryings
and insecurities, I'm pretty solid, and while I worry about the challenges of meeting my
responsibilities, I haven’t been hollowed out the way that
Hyland was.

My situation is severe, no doubt
about it. But my sense of self is strong
and the joys in my life are overflowing. Yes, the challenges of a physical impairment like this are huge. One day you're worrying about little
more than putting on weight and trying to “get fit” and the next the very
basics of reaching and moving and breathing are all called into question
every moment of every day. Putting on the dress shirt and tie is a ten minute operation that requires all of my concentration and can leave me (briefly) exhausted. Suddenly the future is more uncertain than it has ever seemed to be. But the challenges fall into two distinct camps – the physical and the psychological. The
psychological are far more important.

My father, and Lynn, my beloved,
had little patience with the sentimental rhetoric of "fighting" disease. Lynn refuses to be labeled a “cancer
survivor” as if that is the most singular thing she’s done with her life, and
my Dad had no illusions about who was going to win the fight with the black robed
figure in the corner of the room. The most important battle isn't with the physical disease -- it's with the temptation to fall into
despair, to allow oneself to be
defined by the struggle with the disease, to let the pain and the fear blind
you to joy and delight and the love of
those around you.

Two months before he died, my Dad
and I went for a flight in a little bi-plane.
His laughter, his glee when he
cackled, “I’ve got nothing to lose! You
should be worried,” are what characterize those last months. Lynn coming into the AAHSL meeting in a
low-cut blouse with the X of the black tape clearly marking the radiation site
so that people would feel permission to ask her how she was doing, changed the lives of some women. We know
this, because they have told her, privately, their stories of how her example
made them stronger and bolder when they had to face their own mortal crises. Lynn is in so many ways a very private person, but giving the finger to breast cancer in very public ways was the response that made the most sense to her.

It wasn’t their diseases that
Lynn and my Dad were fighting. It was
the terror lodged in their own hearts.
It was the temptation to be absorbed by grief and loss and to become blinded to the beauty and joy that still exists around all of us. And they transcended. Two months
after that plane ride my father was dead, the spectre in the corner having given him a few more
graceful months than any of us expected, and leaving me with a lesson about dying as deeply profound as the lessons he'd given me about living.

For now Lynn is cancer free, but being a “cancer survivor” is among the
least of her distinguishing characteristics. That was just one more darkness to make her way through, with grace and humor and gladness. Just one more along the way. What matters is the way she leans on love to vanquish the terror in the heart.

June 29, 2013

In the spring of 2010 I read Indigo's Mermaid in Aleksander Hemon's anthology, Best European Fiction 2010. It was the best of the lot and though it seemed like the quietest story in the world, I was startled by how suddenly the last sentence humbled me into tears of gratitude. (I just read it again and the same thing happened). A remarkable tale of forgiveness and kindness, two achingly real people etched "in just a few confident incisions."

From the author's note I learned that Simpson lived in Wales and that she had published one novel and was working on a second. Jake managed to get me a copy of the novel, The Banquet of Esther Rosenbaum and I read it that summer. Here's part of what I scribbled in the back flap: "Spectacular characters and story, within the amazing frame of Esther's consciousness..." It had all of the things that I look for in a novel, the meticulously crafted sentences that pull the reader along and illumine the real lives of the characters in a setting and a story that is rich and complete as it surrounds you and carries you away.

I got a copy of The Deer Wedding not long after it came out and finally got to it a couple of weeks ago -- just as impressive and completely different, although certain themes and approaches crop up again. I wouldn't want to rank writers of this caliber -- I'll just point out that I've been reading Nabokov and Harrison and Chabon and Butler and Updike this spring and Simpson holds her own.

So then I had to get a copy of her 2003 short story collection Dog Days. Long out of print, but used copies are easily findable. Mine showed up on Tuesday and I finished it last night. Simpson shows an amazing generosity of spirit to her characters, damaged peopled in terrible straits, making lives out of the few fragments they've been given to work with. For a long time I will be hearing the giggles of Caitlin and her Mam.

She says she's working on the 2nd draft of her next novel. It can't come soon enough. And for this one, I hope she can work a deal that will get her wider attention in the States. Her work deserves it.

May 24, 2013

We talked for a long time after dinner last night, about the multitude of swirling adventures that characterize our lives these days. At one point she said, "You look so sad when you're moving around." She hastened to add that she didn't mean that I was sad, but that the people who care about me see me struggle and it makes them sad.

I get that. I see it behind the smile on Billie's face when she watches me pass from my office in front of her desk on the way to wherever I need to be next. Or I'll be in a meeting with some of the Deans and as the meeting breaks up someone will sidle up to me and ask, "So how are you doing?" and I give them a brief update. But when I'm in the meeting, I can forget about it and be fully engaged with the work I love to do. I'm sorry that I cause them worry, but I am so grateful for their tenderness and concern.

M., my very astute therapist is working on my gait. She laughs as she watches my Tin Man walk. "A PT instructor would love you -- the PT students would hate you!"

"Why's that?"

"There's just so many things..." She puts a finger to her chin. "I'm just trying to decide what I'm going to fix next." She radiates confidence.

Like I've said -- I'm great teaching materiel.

Who knew that walking was so complicated? My ankles & toes & hips & knees & arms are all ready to do the work, but the brain can't get the right signals to them. So we work on retraining -- swing the arms, raise the knee when you stride, don't sashay those hips! Heel to toe, heel to toe. So much to remember! C'mon little nerve fibers -- you can sort out the new pathways.

I tell her that now when I see somebody running up the stairs I want to shout, "Do you realize how amazing what you're doing is?" And M. grins and says, "And then you want to smack 'em?"

But no. I don't carry any of that kind of anger. I just find the whole damn thing fascinating. I am learning so much.

Today it's a beautiful early summer day in Alabama. I walked around the edge of the lake to the spillway, practicing. Swing the arms, shoulders relaxed, heel to toe, heel to toe, don't sashay those hips!

April 27, 2013

“Right there,” says the neuroradiologist, poking her finger at the screen and
sounding slightly exasperated. “The
enhancement is definitely worse there than on the March 25th scan.” The neurologist leans in, looking back and
forth between twin images of my spinal cord.
He shakes his head slightly. “I’m still not seeing it.” She enlarges the
images. “Right there,” she says
again. “It’s obvious.”

The neurosurgeon stands behind
them, arms folded. He says nothing. He
doesn’t see it either, but he’s not the one who spends all day in a dark room
looking at scans. Maybe the enhancement is worse. But he still doesn’t see anything he can cut. And unless he’s sure what he’s going after he’s
not going in.

At least, that’s how I imagine
the scene a little while later as the neurosurgeon stands at the foot of my
hospital bed explaining the current consensus (there are at least four
world-class physicians working on my case).
I’ve been here since yesterday morning when my neurologist decided I
needed another MRI. I’ve been doing
pretty well overall but the March 25th scan didn’t show the expected
improvement in the spinal cord swelling.
And although two weeks ago I was walking all over Dublin after five days in Bournemouth, this past
Saturday and Sunday I felt like I was struggling just to make it down to the
end of my street. So Dr. B. decided he
wanted another image, and the fastest way to do that was to check me back into
the hospital. I’ve had nothing to eat
since last night and no coffee yet today, on the off chance that I’d need surgery. I was as pleasant as I could be this morning
to the three doctors and five medical students who crowded into my room to
discuss my very interesting case, but now it’s going on 1:00 and I’m getting
decidedly peckish. So when Dr. O finishes
explaining why he is not doing surgery, my only question is, “Does that mean I
can have coffee now?” He laughs. “Yes, I’ll see that you get some coffee.”

That was Thursday. Now I’m back home, waiting for
the Home Health nurse to come by and infuse me with another gram of steroids. Lynn has a list some twenty items long of
diagnoses that have been considered.
Many have been discarded, but there are still a couple on the list. (Think of what a waste of teaching materiel
I'd be if I weren't in a big academic medical center!) Without the exploratory surgery that Dr. O.
definitely refuses to do they really can’t nail it down any further at this
point. So we’re treating it as an “autoimmune
inflammatory process”. Which simply
means that my overeager white blood cells think there’s something wrong with
the myelin that insulates the nerves in my spinal cord and are eating away at
it, causing severe inflammation and swelling at the neck. To put it simply, there’s a short circuit in
my spinal cord. When my brain tries to
control my legs or hands, the signals get scrambled. If I try to make a fist, the muscles on the backs
of my hands start to contract as well, attempting to pull my fingers straight
when I’m trying to clench them. Makes
forming chords on the guitar damned difficult.
Similarly, when I try to move a leg forward, some of my hip muscles are
trying to pull it back, giving me what Lynn refers to as my “Tin Man” walk. I can do most of what I want to do – it just
requires some extra conscious effort.

The very cautious plan we’ve been
on so far has been no treatment – let’s see what the body does on its own. The latest MRI suggests that the body needs
some help. So we’re starting a regimen
of steroids and a mild immunosuppressant.
That should help.

And in the meantime, of course,
all the rest of life rumbles on and I remain a generally happy guy.

Work is good, and Lynn is ever
her amazing strong magical self (she was with me the entire hospital stay and, seriously, we had a fine time).

The Bearded Pigs play Boston a
week from tomorrow!

Josie came in 3rd on
beam at the Regionals meet at Clemson on Friday morning! Woo-hoo!

December 13, 2012

My interest has always been singing the songs. Playing guitar was the vehicle for doing that. (And yet, when I go down to the basement where my gear is I always say, "I'm going down to play guitar" never "I'm going down to sing." What's up with that?)

I can make my way around my acoustic pretty well, but it's still rudimentary. And despite my three telecasters, I've never spent much time playing with the sounds. In the band I just bang away on the chords trying to keep the rhythm going. They're nice guitars, so I feel guilty about that.

Now, since the objective is to restore dexterity to my left hand (the chording hand), I'm focusing on the guitar sounds. I'll skip the singing for awhile. I've set up one of the small amps with an effects modulator in my study. I'm playing very loud.

One of the most transcendant and luminous pieces of piano music ever recorded is the solo concert that Keith Jarrett did in Cologne back in 1975. I first heard it a few years after it came out (thanks again to the unknown librarian who was selecting albums for the Oshkosh Public Library in those days) and it was one of those recordings that changed my life. I go back to it often and it always refreshes me and brings me new joy.

Only recently did I come across the story of how that concert came about. It was a mess. The stagehands brought out the wrong piano. Not the one that Jarrett had requested, it was in lousy condition, had bad sound, malfunctioning pedals. Jarrett almost refused to go on. Seventeen year old Vera Brandes, the promoter, managed to talk him into it.

And that damn piano forced him to go further into himself, into his technique, into his lyrical imagination than he ever had before. It redefined his career, became the all time best selling piano album and continues to have a tremendous impact. Resistance.

In high school I was baffled by the notion of poetic form. (This was the heyday of free verse). Why would one want to confine oneself that way? Sure, I could enjoy a clever rhyme scheme but that seemed like such a secondary effect. It took me years to understand how pushing against the resistance of form unlocks and opens creativity inside that can't be found in any easy way. The seemingly arbitrary constrictions of the sonnet form are so attuned to the rhythms and sounds of the English language that they can bring a poet to a level of sublimity that a free verse poem is incapable of achieving. Resistance.

I can manage the chord changes to "Rockin' In The Free World" pretty well, even with the numbness in the tips of my fingers. The muscles are fine (it's the nerves that are messed up) and the fingers know where to go. I'm flipping switches and twirling dials and grinning at the woof-woof the amp makes when I slam the Em and let it sustain. It sounds horrible because I don't really know what I'm doing. So I'm pushing. I'm listening. I'm finding new sounds that I never bothered to think about making before. I'm laughing and having a really good time. It's hard. I like that.

December 12, 2012

"There's nothing wrong with your pons," says my neurosurgeon. "I'm not going to order another MRI. They can talk to you about that later if they want one." I've had six already. And he has ordered up nine of the vials of blood they want. He rolls his eyes. "But I'm not ordering that one. Nothing in your history indicates that kind of vitamin deficiency. They're reaching."

"They" are the neurologists, who have been brought in to consult on my case. When the ambulance brought me in, the first worry was stroke, so they called Dr. O., the neurosurgeon on duty and I became his patient. The CT was negative for stroke so he sent me down to the tube. That's when they first saw the inflammation of the spinal cord. O. was still ready to cut if need be, but he wasn't satisfied with what he was seeing. "I'm going to run a contrast MRI so I can get a better look at this." He sent me back to the tube.

By the middle of the 2nd day he was sure he didn't need to cut. There were still four MRIs, a spinal tap and a variety of other tests to go to try to figure out where the swelling was coming from. "But this is out of my area now, so I'll need to call in the neurologists." It was apparent that he was trying to decide whether or not to transfer me to their service or just bring them in to consult. He decided to keep me. "You're an easy patient." He smiled.

But he doesn't have the same kind of curiousity as the neurologists. Like my primary care guy, he mostly wants to figure out what he needs to do to save my life and make me feel better. He knows he doesn't need to cut and he knows that whatever the cause is, massive infusions of steroids give the best of odds of reducing my symptoms in the short term. He'd be interested in knowing why my immune system is gnawing at the myelin sheath, but he's due in surgery this afternoon and that's where his focus is. He's done as much as he can do for me.

For the neurologists, however, my current status is just the beginning. Now their professional curiousity is up. Why is my body doing this? Is it the vitamins after all? Is there some other kind of deficiency? How long has this been happening? Did I have a viral infection at some point? Is it tied into my optic nerve somewhere? Why is it mostly in the cervical area rather than further down -- isn't that unusual? Why is the swelling diffuse along the cord rather than bunched up? Is there another test we can run?

I'm amused by the competitive tension -- the different perspectives of these very calm, but very intense professionals. And it occurs to me that this split may occur, to some degree, throughout the medical professions. There are those, like Mike and like O., who are principally therapists -- they want to fix the problem and get their patients back into their daily lives as quickly and completely as possible. Then there are the diagnosticians like Dr. A. and Dr. S., who really want to know what's going on. We know so little about the nervous system. This is a chance to learn a little more. And then maybe to find a way to treat me a little bit more effectively than their last patient.